Uterine tumors resembling ovarian sex cord tumors: a case report of conservative management in young women.

Uterine tumors resembling ovarian sex cord tumors (UTROSCT) are distinguished into two separate groups: endometrial stromal tumors with sex cord-like elements (Group I), which have an unfavorable prognosis; and UTROSCT proper (group II), with more than 40% sex cord-like differentiation and less endometrial component, which are biologically less aggressive than the tumors of the other group. We report the case of a young woman with UTROSCT treated by minimally invasive hysteroscopic surgery. This is one of the few cases reported in the literature that have been managed conservatively.

Cervical length as a predictor of preterm delivery: gestational age-related percentiles vs fixed cut-offs.

BACKGROUND: To determine whether preterm delivery is more effectively predicted by sonographic cervical length measurement using fixed cut-off or gestational age-specific percentiles. METHODS: One hundred and eight patients hospitalized for suspected preterm labor (PTL) were studied prospectively between the 20th and the 33rd week of gestation. RESULTS: Cervical length below 15 mm, 25 mm and the 2.5th centile showed substantially equivalent odds ratios for delivery within 7 days (7.5, 7.6, and 7.1, respectively), while for delivery before the 34th week the odds ratios varied between 3.6 with cervical length <2.5rh centile and 6.2 with cervical length <25 mm. Moreover, the negative predictive value for delivery within 7 days exceeded 90% when cervical length was above 25 mm, the 10th and the 2.5th percentile, and 85% when above 15 mm. CONCLUSION: The comparison of fixed and gestational age-specific cut-offs demonstrates a better reliability of fixed cut-offs (15 or 25 mm) in predicting preterm delivery, both before 34 weeks and within 7 days of the ultrasound examination.

Ultrasound screening in second and third trimester of pregnancy: an update.

Ultrasound screening of structural fetal malformations is mainly based on the use of ultrasounds during the second trimester of pregnancy. The diagnostic sensibility of ultrasounds varies in the different multicentric studies reported in literature and is correlated to different factors: gestation period, type of malformation, number of ultrasounds performed, operator experience, etc. Third trimester ultrasounds may identify late-onset malformations and offer adequate information for postnatal assistance.

Second-trimester maternal serum alpha-fetoprotein elevation and its association with adverse maternal/fetal outcome: ten years experience.

BACKGROUND: Alpha-fetoprotein (AFP) is the major serum protein in the embryonic stage and in the early fetal stage. The aim of this study was to determine any possible association between an "unexplained" elevation of maternal serum alpha-fetoprotein (MSAFP) levels in the second trimester of pregnancy and adverse maternal/fetal outcome. METHODS: A retrospective cohort study, was carried out in the University of Parma, by reviewing all triple tests that had been found positive for neural tube defect screening, showing an "unexplained" MSAFP elevation (> or =2.5 multiples of the median [MoM]), which could not be ascribed to any apparent reason. These results were compared with those of negative controls (MSAFP <2.5 MoM) in order to evaluate the course and outcome of pregnancy. Statistical analysis was performed by chi-square test, Fisher's exact test, Student's t-test, and odds ratio calculation. RESULTS: We reviewed 16,747 tests: 143 tests with high MSAFP levels were found, including 105 data already available. Out of them 21 tests were excluded from the study because of the presence of fetal malformations, chromosomal diseases, or late miscarriage. Among the 84 remaining pregnancies, 43 were significantly associated with increased rates of pregnancy pathology compared with the control group of 199 patients, with 25 complicated pregnancies. In addition, high MSAFP levels were correlated with a less favorable neonatal outcome in terms of low birth weight, Apgar score, and transfer to a neonatal intensive care unit. CONCLUSIONS: Unexplained elevation of MSAFP levels in the second trimester of pregnancy is associated with an adverse maternal/fetal outcome, possibly suggesting the need for a more strict management of pregnancies.

Changes in interleukin-6 and IGF system and their relationships in placenta and cord blood in newborns with fetal growth restriction compared with controls.

OBJECTIVES: The IGF system is central to fetal growth. Recently, the relationships between cytokines and the IGF system have been shown in specific tissues. It is unknown whether these occur in the placenta. The aim of this study was to assess whether interleukin-6 (IL-6) modulated the IGF system. METHODS: Whole villous tissue and cord serum were collected from fetal growth restriction (FGR) neonates diagnosed before birth with altered Doppler velocimetry and controls. Sixteen FGR and 20 controls, born after week 32 of gestation from elective Caesarean sections, were compared. Total RNA was extracted from the placenta samples, reverse transcribed, and real-time quantitative reverse transcriptase (RT)-PCR was performed to quantify cDNA for IGF-I, IGF-II, IGF binding protein (IGFBP)-1, IGFBP-2, and IL-6. The same proteins were assayed in placenta lysates and cord serum using specific commercial kits and western immunoblotting. RESULTS: FGR subjects had significantly more IGFBPs-1 and -2, and IL-6 mRNA and corresponding proteins in the placenta. In particular, the less phosphorylated isoforms of IGFBP-1 were highly increased. IL-6 and IGFBPs-2 mRNA, and IL-6 and IGFBP-1 peptides were positively and significantly correlated in the placenta. The IGF-II peptide was also significantly increased in FGR placentas. In cord serum, IGFBPs-1 and -2 were significantly more elevated in the FGR neonates. Serum IL-6 was significantly and positively correlated with both IGFBP-1 and IGFBP-2. CONCLUSIONS: The placenta of FGR neonates has higher IGF-II, IGFBP-1, IGFBP-2, and IL-6 contents compared with controls. At birth, IGFBPs-1 and -2 are increased in the cord blood of FGR neonates. IL-6 and IGFBP-2 gene expressions are closely related in the placenta. We suggest that the increase in IL-6 and IGFBP-2 could be subsequent to hypoxia and nutrient deficiency. As IGFBP-2 has a strong affinity for IGF-II, which is crucial for fetal growth, it could be an important bioregulator of IGF-II in the placenta.

Diagnostic accuracy of fetal renal pelvis anteroposterior diameter as a predictor of significant postnatal nephrouropathy: second versus third trimester of pregnancy.

OBJECTIVE: The objective of the study was to determine the most effective fetal renal pelvis anteroposterior diameter thresholds and the best gestational age in predicting significant neonatal nephrouropathy and neonatal nephrouropathy requiring surgery. STUDY DESIGN: Eighty-three newborns with prenatal ultrasound evidence of unilateral or bilateral fetal renal pelvis dilatation (anteroposterior diameter 4 mm or more) before the 26th week of gestation were systematically and prospectively investigated prenatally and postnatally. RESULTS: Receiver operating characteristic curve analysis showed that third-trimester anteroposterior diameter cut-offs were more reliable than second-trimester cut-offs in predicting significant neonatal nephrouropathy, the best threshold being 8 mm. No significant differences were found between the 2 trimesters in the screening of fetuses at risk of neonatal nephrouropathy requiring surgery. CONCLUSION: Significant neonatal nephrouropathy is better predicted at the third trimester, the best threshold being 8 mm, but the screening of patients at greater risk of surgery is also possible during the second trimester. An anteroposterior diameter of 11 mm or more, with an odds ratio of 128.33 (95% confidence interval 11.68 to 1408.98), is a very effective cut-off and a reliable prognostic indicator of neonatal nephrouropathy requiring surgery, even before the 26th week.

Clinical management of paroxysmal nocturnal hemoglobinuria in pregnancy: a case report and updated review.

UNLABELLED: Because women with paroxysmal nocturnal hemoglobinuria (PNH) are especially vulnerable to thromboembolic phenomena, pregnancy is a time of increased risk for both mother and fetus. However, pregnancies in affected women are rare; only case reports and small studies have been reported so far. We present the case of a 20-year-old woman with PNH who, while undergoing medical tests in preparation for a bone marrow transplant, was discovered to be pregnant. We also review the obstetric literature on pregnancy complicated by PNH, which indicates that both maternal and fetal mortality is exceptionally high (11.6% and 7.2%) with the major cause of maternal mortality being thromboembolism. Major maternal complications are more frequent postpartum (30.2%) than antepartum or intrapartum (16.3%). TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to recall that paroxysmal nocturnal hemoglobinuria (PNH) during pregnancy increases adverse events for both the mother and the fetus, state that maternal and fetal mortality are both high, and explain that the major complications occur in the postpartum period.

Retzius' space haematoma after spontaneous delivery: a case report.

We report a case of a haematoma of the Retzius space after spontaneous uncomplicated delivery. In the postpartum period, the patient complained of urinary retention and pain in the hypogastric region radiating to her left hip and leg. The ultrasound examination showed the presence of 160 x 100 x 80 mm confluent solid and liquid areas with peripheral vascularization. At exploratory laparotomy a haemorrhagic infiltration was found in Retzius' space and the anterior wall of the bladder, which appeared thickened and swollen below the peritoneum. We tried to drain the haematoma, however, we failed to drain it completely because of the large blood infiltration in the bladder wall. Clinical and ultrasound follow-up examinations showed a progressive reduction of the haematoma which completely disappeared nine months later. The haemodynamic changes occurring during pregnancy and labour, associated with strong mechanical stress, seem to be among the major causative factors of haematoma formation. Moreover, the venous load in the pelvic vascular system is increased during pregnancy; a stress-induced increase in venous blood pressure might play a prominent role, especially in cases of venous ectasia, where the resistance of blood vessel walls is reduced. Intraoperative evidence seemed to suggest a haemorrhage secondary to the rupture of the venous vessels in the Santorini plexus. The rupture was probably caused by the thrust of the fetal head, associated with abnormality or fragility of the blood vessels, or by some pathologic changes occurring in the anatomical structures during pregnancy, which could not be accurately defined because of the severity and degree of the haematoma infiltration found intraoperatively.

Twin-twin transfusion syndrome: a review of treatment option.

OBJECTIVE: The twin-twin transfusion syndrome (TTTS) is a complication of monozygotic-monochorionic twinning and is a direct result of transplacental communication between the circulations of twins. When acute TTTS occurs in the second trimester, the perinatal mortality can be as high as 95% in the absence of treatment. For this reason, several aggressive, even desperate treatment modalities have been attempted including selective fetocide, umbilical cord ligation, maternal digoxin therapy. None have gained wide acceptance. Serial drainage amniocentesis or amnioreduction is actually the most widely used therapy. More recently, laser ablation under fetoscopic guidance of placental vessel has been reported in an attempt to improve survival. The objective of this review was to evaluate the impact of treatment modalities in TTTS. STUDY DESIGN: Reports of prospective and retrospective trials and other study designs in English identified from searches of MEDLINE, EMBASE, specialized databases, bibliographies of review articles. Study on twin pregnancies affected by TTTS between 1990 and 2003 that met our inclusion criteria were included. RESULTS AND CONCLUSIONS: No single therapy is associated with a uniformly improved outcome for the involved twins and success is primarily related to gestational age and severity at diagnosis. Standard therapy has commonly been serial amnioreduction, which appears to improve the overall outcome. Intertwin sepstostomy similary improves outcome but has no survival advantage over serial amnioreduction. Selective fetoscopic laser photocoagualtion has emerged as an alternative treatment strategy in TTTS with at least comparable if not superior survival to serial amnioreduction. TTTS diagnosed before 26 weeks' gestation has significantly better survival rates and fewer neurological sequelae after laser therapy than amnioreduction.

Alteration of the amniotic fluid and neonatal outcome.

Quantitative and qualitative alterations of the amniotic fluid complicate 7% of the pregnancies. Polyhydramnios complicates 1-3% while oligohydramnios involves 3-5% of the pregnancies. The most common causes of polyhydramnios are fetal abnormalities, maternal diabetes and twin pregnancies, but are idiopathic in the 60%. Perinatal mortality has been reported to range between 10-30% while the risk of preterm birth reaches up to 22% in pregnancies complicated by polyhydramnios. The neonatal outcome, in cases where polyhydramnios is due to fetal-neonatal abnormalities, depends on the underlying pathology. Polyhydramnios due to defects in intestinal canalisation in particular, has been correlated to good neonatal prognosis. In our experience no early postoperative deaths occurred in a group of 16 newborns consequtively admitted to our unit in the last two years, with abnormalities of the gastrointestinal tract with need of surgery within the second week of life. Most cases of oligohydramnios are due to premature rupture of membranes, other causes are fetal abnormalities, such as urinary tract malformations, or chromosomopaties and drugs e.g. NSAID's. Oligohydramnios of mild entities is often associated to preterm birth, fetal growth restriction. In some cases of oligohydramnios, neonatal survival is highly conditioned by pulmonary hypoplasia which develops with rates that range between 13 and 21%. Neonatal prognosis is often disastrous in cases with severe oligohydramnios, which however could be improved by amnioinfusion, which restores an amniotic fluid volume sufficient in reducing the adverse environmental effects and in prolonging, where possible, pregnancy. Beside the quantity also the quality of the amniotic fluid may be related to the neonatal outcome. Finding of some inflammatory factors (interleukines) in the amniotic fluid seems to be significantly correlated to periventricular leucomalacia (PVL), cerebral paralysis and long-term neurological abnormalities, both in the preterm and term neonate. Therefore, increase of the cytokines in the amniotic fluid could give information not only of the infection but also regarding the risk of developing neurological sequelae in neonatal period. Diagnosis and therapy for pathologies that alter the amniotic fluid have progressed, however efforts have still to be made in the identification and search for those quantitative-qualitative alterations of the amniotic fluid, for their potential implications on neonatal outcome.

Early complications of prenatal invasive diagnostics: perspective analysis.

In this retrospective analysis we studied 1489 women who underwent prenatal invasive diagnostic procedures between January 2000 and December 2002. We examine the influence of risk factors and the incidence of early complications following amniocentesis and chorion villus sampling, in particular the incidence of fetal loss. The study group included 438 women who underwent CVS and 1051 underwent amniocentesis. For each woman we studied anamnestic risk factors (recurrent pregnancy losses, fibroids, twin birth, uterine hematic loss), intraoperative risk factors (repetition of the insertion, transplacental sample, hematic liquid, early bleeding) and postoperative risk factors (pelvic pain, hematic losses, liquid losses, spastic pain, fever). In our data the miscarriage incidence was 1% for CVS and 1.7% for amniocentesis. Our results showed that in relation to CVS, the presence of fibroids gives an OR of miscarriage of 68 (95% C.I.=6.50-659.78; p=0.000). In relation to amniocentesis, the incidence of hematic losses gives an OR of miscarriage of 10 (95% C.I.=1.50-32.94; p=0.04). If these results were confirmed by other experiences, they could induce obstetricians to avoid CVS in these women with uterine fibroids and hence recommend amniocentesis to them. Particular attention has to be taken in those patients with vaginal bleeding following amniocentesis.

Ultrasound evaluation of amniotic fluid volume: methods and clinical accuracy.

Ultrasound evaluation of amniotic fluid volume (AFV) is frequently used to detect fetuses at high risk for an adverse outcome - an event that is often correlated with AFV abnormalities. As is well known, ultrasound is a non invasive procedure, which makes it ideal for application on a very large scale: in practice, it can be used for routine monitoring of all pregnancies and, not infrequently, for repeat AFV determination in those cases where there is the suspect of amniotic fluid abnormalities. Sonographic quantification of AFV, whether it is performed through a simple visual estimation or through biometric measurement of one or more amniotic fluid pockets, can never represent a true "quantitative" method and its actual reliability has not consistently been proved by scientific evidence. Moreover, even though ultrasound AFV evaluation is indispensable in the management of high-risk pregnancies, there is no consensus on which ultrasound index is the most accurate in predicting perinatal morbidity and mortality. The sonographer can evaluate AFV by directly observing amniotic fluid pockets and his experience is crucial for a high reliability of the procedure. When pathological AFV changes are present, especially if the examination is performed by a not so expert sonographer, biometric measurements (Single Deepest Pocket, Amniotic Fluid Index, Two-Diameter Pocket) with their respective reference ranges might be helpful in confirming the diagnosis of oligohydramnios or hydramnios. A complete review of all tests performances and confidences is made by the Authors.

Amnioreduction for treatment of severe polyhydramnios.

Between January 2000 and March 2003 we studied the pregnancies complicated by polyhydramnios in 10 patients. The objective was that of evaluating the efficacy of amnioreduction in improving the principal complications given by polyhydramnios such as maternal dyspnea and uterine activity. Our results showed that this procedure resolve maternal symptoms in all the cases but there is no significant reduction in uterine activity.

Amniotic fluid index versus largest vertical pocket in the prediction of perinatal outcome in post-term pregnancies.

We studied a cohort of 41 singleton pregnancies induced at term with prostaglandins and, when necessary, oxytocin. We evaluated with ultrasound the amniotic fluid index (AFI) and the largest vertical pocket (LVP), at least 2 days before the delivery, to compare the sonographic measurement of amniotic fluid with fetal distress and perinatal outcome. We analysed the incidence of fetal distress using intrapartum monitoring of fetal heart rate, considering the absence of variability, the presence of persistent severe variable and/or late decelerations. The oligohydramnios group, indipendently by ultrasound index, showed the same incidence of abnormal FHR, and rate of Cesarean section for fetal distress as the group with normal amniotic fluid. In conclusion there is no significant difference between the group of patients with oligohydramnios and the one with normal amniotic fluid regarding the perinatal outcome in induced labor.

Role of D-dimer testing in severe pelvic inflammatory disease: a new usable marker to assess the need for fertility-impairing surgery?

Pelvic inflammatory disease (PID), like many other inflammatory diseases, can be characterized by an inflammation-induced activation of the coagulation cascade, resulting in the production of D-dimers. In this study it is demonstrated how high levels of D-dimers, assayed at the time of hospitalization, are encountered in patients diagnosed with PID and how the levels of this parameter are significantly higher in patients, which due to the severity of the disease, needed surgical treatment. Therefore the d-dimer is shown to be an important parameter to be considered in the therapeutic counseling of severe forms of PID.

Effect of physical training on age-related reduction of GH secretion during exercise in normally cycling women.

OBJECTIVE: To evaluate whether prolonged physical activity (25 km/week running for 8 years) modifies GH decline. DESIGN: The GH response to maximal exercise on bicycle-ergometer was tested in younger (26-30 years) and older (42-46 years) healthy women. Each age group included 2 subgroups of 10 sedentary and 10 runners, which were compared. The workload was increased at 3 min intervals from time 0 until exhaustion. Subjects with a low maximal capacity (as established in a preliminary test) pedalled for 3-4 min against no workload at the beginning of the test, so that exercises lasted about 15 min in all individuals. RESULTS: At exhaustion, heart rate and systolic pressure were significantly higher in sedentary than in trained subjects, whereas V(O(2)max), blood glucose and plasma lactate levels were similar in all groups. Exercise induced similar GH responses in younger sedentary and exercise-trained subjects and in older exercise-trained subjects, with mean peak levels 7.5 times higher than baseline. In contrast, in older sedentary women peak GH level was only 4.4 times higher than baseline and was significantly lower than in the other groups. CONCLUSION: These data suggest that in women prolonged physical training exerts protective effects against age-dependent decline in GH secretion.

Intrapancreatic rupture of a splenic artery aneurysm during pregnancy - a rare case report with fetal and maternal survival.

Rupture of a splenic artery aneurysm (SAA) during pregnancy is a rare and severe condition. A 35-year-old woman at 34 weeks' gestation came to our observation for acute abdominal pain. After being diagnosed with intra-pancreatic SAA rupture, she was delivered of a live fetus by cesarean section. This is a rare case with both fetal and maternal survival.

Association between fetal Doppler velocimetry abnormalities and confined placental trisomy 22: A case report.

The occurrence of trisomy 22 confined to the placenta is rare. We report on a patient who presented with fetal abnormal Doppler velocimetry (elevated umbilical artery pulsatility index), but serial ultrasound examinations revealed a spontaneous recovery throughout pregnancy. A healthy baby was normally delivered at 40 weeks.

Diagnostic accuracy of IOTA ultrasound morphology in the hands of less experienced sonographers.

AIM: The purpose of our study was to evaluate the ability of the International Ovarian Tumor Analysis (IOTA) classification and its impact on the identification of benign and malignant adnexal masses by less experienced sonographers. METHODS: One hundred and five patients undergoing elective surgical treatment for single adnexal masses at the University of Parma were enrolled. After the final diagnosis, we had the ultrasound recordings reviewed retrospectively by a group of three residents, and the features of each adnexal mass were evaluated according to the morphological score reported by the IOTA Group. RESULTS: Based solely on the qualitative classification of the IOTA Group unilocular cysts were associated with a high, significant probability of a benign lesion (odds ratio (OR) = 12.6 (95% CI, 1.61-99.10), P < 0.001). This probability remained high also with multilocular cysts (OR = 7.9 (95% CI, 1.00-62.38), P < 0.05). By contrast, multilocular-solid cysts were significantly associated with the probability of malignancy (OR = 6.4 (95% CI, 1.81-22.70), P < 0.001), as were solid masses (OR = 5.5 (95% CI, 1.48-20.92), P < 0.05). None of the five ultrasound categories of lesions could be significantly correlated with borderline masses. CONCLUSIONS: A simple qualitative classification based solely on the recognition of five different ultrasound categories may be enough to guide the physician to an accurate identification of the nature of the mass. Our findings confirm the diagnostic reliability of the IOTA Group classification by less experienced sonographers. This system is especially helpful because it is capable of discriminating between ovarian masses without further tests and clinical examinations.

Mid-trimester amniocentesis and antibiotic prophylaxis.

OBJECTIVES AND METHODS: Assuming that the rate of fetal loss after amniocentesis may be reduced in patients receiving antibiotic prophylaxis, we conducted a retrospective study on untreated versus treated patients receiving prophylactic antibiotics (amoxicillin/clavulanic-acid or azithromycin) and evaluated the fetal loss rate within the 22nd week of gestation, also with respect to the risk of spontaneous abortion, both preexisting and related to mid-trimester amniocentesis. RESULTS: Spontaneous abortion occurred in 22 cases out of 1744 (1.26%). The incidence of spontaneous abortion was 1.3% among patients treated with antibiotic prophylaxis and 1.2% among untreated patients. Between patients with risk factors that predated amniocentesis, the spontaneous fetal loss rate was 9.2% in untreated patients versus 2.3% in patients treated (p = 0.10). In patients with procedure-related risk factors at amniocentesis, the spontaneous abortion rate was, respectively, 2.2 and 1.2% (p = 0.72). CONCLUSION: Our data demonstrate that antibiotic prophylaxis does not reduce the risk of spontaneous abortion within the 22nd week of gestation. Compared with untreated patients, patients treated with amoxicillin showed the lower fetal loss rate (1.16 vs 0.31%), but the difference was not statistically significant (odds ratio (OR) = 3.68, p = 0.32). The same was true for patients with preexisting risks (OR = 4.25, p = 0.10).